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v1.0.0
ICD-10 Guide
ICD-10 CodesZ38.3

Z38.3

Twin liveborn infant, born in hospital

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/12/2025

Code Description

ICD-10 Z38.3 is a billable code used to indicate a diagnosis of twin liveborn infant, born in hospital.

Key Diagnostic Point:

Z38.3 is used to classify a twin liveborn infant who was delivered in a hospital setting. This code is essential for capturing the birth of twins, which can have unique clinical considerations and social determinants influencing health outcomes. Factors such as maternal health, socioeconomic status, and access to prenatal care play a significant role in the health status of both the mother and the infants. Preventive care for twins includes regular monitoring for potential complications such as low birth weight and developmental delays. Screening for congenital conditions is also critical in the early stages of life. Aftercare for twin infants often involves coordinated care between pediatricians and specialists to ensure optimal growth and development. Documentation must reflect the circumstances of the birth, including any complications or interventions, to support the use of this code.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Need for accurate documentation of twin births and any complications.
  • Potential for multiple diagnoses related to maternal and infant health.
  • Variability in aftercare needs for twins compared to singletons.
  • Importance of capturing social determinants affecting health outcomes.

Audit Risk Factors

  • Inadequate documentation of the birth process and complications.
  • Failure to capture relevant maternal health conditions.
  • Misclassification of the infant's birth order or type.
  • Lack of follow-up documentation for aftercare services.

Specialty Focus

Medical Specialties

Primary Care

Documentation Requirements

Documentation should include prenatal care details, birth complications, and follow-up visits.

Common Clinical Scenarios

Routine checkups for twins, developmental screenings, and immunizations.

Billing Considerations

Consideration of social determinants such as family support and access to healthcare services.

Public Health

Documentation Requirements

Population health data collection, monitoring of twin birth outcomes, and health disparities.

Common Clinical Scenarios

Epidemiological studies on twin births and preventive health initiatives.

Billing Considerations

Tracking health outcomes related to socioeconomic factors and access to care.

Coding Guidelines

Inclusion Criteria

Use Z38.3 When
  • Z codes are used to indicate factors influencing health status and contact with health services
  • 3 should be sequenced appropriately, often following any primary diagnosis related to the mother or infant health
  • Payer requirements may vary, so it is essential to verify specific guidelines with insurance providers

Exclusion Criteria

Do NOT use Z38.3 When
No specific exclusions found.

Related CPT Codes

99391CPT Code

Preventive medicine visit, infant

Clinical Scenario

Used for routine check-ups for twin infants.

Documentation Requirements

Document growth metrics, developmental milestones, and any concerns.

Specialty Considerations

Consider the unique needs of twins in preventive care.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for greater specificity in coding twin births, improving the accuracy of health data and enabling better tracking of health outcomes for twins.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for greater specificity in coding twin births, improving the accuracy of health data and enabling better tracking of health outcomes for twins.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for greater specificity in coding twin births, improving the accuracy of health data and enabling better tracking of health outcomes for twins.

Resources

Clinical References

  • •
    CDC Guidelines on Twin Births

Coding & Billing References

  • •
    CDC Guidelines on Twin Births

Frequently Asked Questions

What documentation is required for coding Z38.3?

Documentation must include details of the delivery, any complications, and follow-up care for the twins. It should also reflect any relevant maternal health conditions that may impact the infants' health.